Atlas of Oculoplastic and Orbital Surgery Thomas C Spoor AT L A S O F O C U L O P L A S T I C A N D O R B I TA L S U R G E RY Thomas C Spoor MD, FACS Professor Emeritus Departments of Ophthalmology and Neurosurgery Wayne State University School of Medicine and Oculoplastic and Orbital Surgery St John Hospital System, Detroit, Michigan and Sarasota Retina Institute, Sarasota, Florida USA © 2010 Informa UK First published in 2010 by Informa Healthcare, Telephone House, 69-77 Paul Street, London EC2A 4LQ Informa Healthcare is a trading division of Informa UK Ltd Registered Office: 37/41 Mortimer Street, London W1T 3JH Registered in England and Wales number 1072954 All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the publisher or in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 0LP Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention A CIP record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Data available on application ISBN-13: 978 841 84586 Orders from Informa Healthcare Sheepen Place Colchester Essex CO3 3LP UK Telephone: +44 (0)20 7017 5540 Email: CSDhealthcarebooks@informa.com Typeset by Exeter Premedia Servies Private Ltd., Chennai, India Printed and bound in Great Britain by MPG Books Ltd, Bodmin, Cornwall, UK Contents Dedication Foreword Preface iv v vi Lower Eyelid Surgery Ectropion Repair 16 Entropion Repair 26 Lower Eyelid Retraction 32 Complications of Lower Eyelid Surgery 38 Upper Eyelid Surgery 48 Complications of Upper Eyelid Surgery 73 Tearing and Dry Eye—Evaluation and Treatment 84 Orbital Surgery, Optic Nerve Sheath Decompression, and Temporal Artery Biopsy 95 Index 118 iii Dedication I would like to dedicate this book to those who made me what I am (for better or worse) My parents Herbert and Edna Spoor, my wife Deanne and daughter Kristen I also thank the members of the oculoplastic service at the New York Eye and Ear Infirmary where I was an OR technician and a resident Many are long dead but are still quoted and remembered Thanks also to my preceptor in Orbital surgery Dr John S Kennerdell for giving me an opportunity to a unique fellowship in orbital disease Thanks also to my many fellows and residents Their input, ideas and mistakes were always stimuating iv Foreword One might appropriately ask whether there is a need for yet another atlas of oculoplastic surgery Dr Thomas Spoor has nicely compiled and detailed his personal experience with common oculoplastic conditions over his nearly 30 years of practice This book, while not claiming to be comprehensive, emphasizes more of the common oculoplastic conditions likely to present to a busy comprehensive ophthalmologist with an interest in oculoplastic conditions There are nine chapters in the book and the first seven deal with the eyelids Separate chapters on complications of upper eyelid and lower eyelid surgery are timely and helpful Another chapter devoted to the evaluation and treatment of tearing and a dry eye contains many practical pearls The final chapter is much more specialized and deals with temporal artery biopsy, orbital surgery, and optic nerve sheath fenestration The last two procedures are more fitting for an oculoplastic or neuro-ophthalmic surgeon The chapters are short and practical with helpful hints and suggestions to avoid or manage complications Surgical points are emphasized with many patient photographs For the conditions listed and the procedures described, Dr Spoor’s techniques have stood the test of time Dr Spoor’s new surgical atlas is a useful addition to anyone’s library James A Garrity MD Whitney and Betty MacMillan Professor of Ophthalmology Mayo Clinic Rochester, MN v Preface Over 50 years ago, three surgeons in New York—Byron Smith, Wendell Hughes, and Sidney Fox—working quite independently, realized that plastic surgery around the eye was different The eye has special needs and should be treated in a special manner to protect its function Since its inception two generations ago, oculoplastic surgery has constantly evolved What was once dogma may now be passé Procedures that were once passé may be resurrected and utilized again The only constant in oculoplastic surgery is change and evolution Although I learned this specialty from some of the best in the business, little I today is the way it was taught to me Thirty years of teaching residents and fellows modifies conventional wisdom and we all learn from one another There is a need to describe practical, simple surgical techniques allowing the comprehensive ophthalmologist to manage basic eyelid and orbital disorders in a safe and effective manner There is also a need for younger or inexperienced oculoplastic surgeons, neuro-ophthalmologists, and plastic surgeons to benefit from the mistakes and successes of an experienced practitioner The practice environment 30 years ago was much less competitive and more forgiving, providing a large volume of surgery and allowing for a great deal of innovation vi This book presents a practical, problem-oriented guide to the management of common oculoplastic and orbital disorders These are mostly simple solutions to often-complicated problems that I have learned over a lifetime of academic and private practice The procedures are described with surgical photos and illustrations in a casual, didactic fashion, as I would use instructing a resident or fellow This is not an all-encompassing, encyclopedic text but a practical, somewhat dogmatic approach to the management of common eyelid and orbital disorders I describe these procedures in a step-by-step manner, which should be very user friendly and has successfully educated a generation of ophthalmology residents and fellows This book will teach you to avoid and manage surgical complications and provide guidance for performing a variety of oculoplastic and neuro-ophthalmic surgical procedures effectively and quickly, as developed over a busy 30-year surgical career with extensive input from a plethora of residents and fellows There may be better ways to perform these procedures but not many Thomas C Spoor md, facs Lower Eyelid Surgery BASIC LOWER EYELID BLEPHAROPLASTY—TRANSCONJUNCTIVAL Basic Anatomy There are three fat pads in the lower eyelid: medial, central, and lateral (Fig 1.1) The inferior oblique muscle separates the medial from the central fat pad (Fig 1.2) When approaching the lower eyelid via a transconjunctival incision, this is really all you need to know As the conjunctival flap is dissected and the eyelid is retracted, the fat pads become readily apparent (Fig 1.3) The orbital septum and capsulopalpebral fascia are retracted with the rest of the eyelid (Fig 1.3A) Most transconjunctival dissections of the lower eyelid are done behind the orbital septum, directly exposing the orbital fat pads Deep to the orbital fat is the capsulopalpebral fascia, which is analogous to the levator aponeurosis in the upper eyelid (Fig 1.1) The capsulopalpebral fascia needs to be identified and reattached to the tarsus to properly repair an involutional entropion (see chapter “Entropion Repair”) Transconjunctival blepharoplasty with or without a tarsal strip procedure is the mainstay of lower eyelid surgery The vast majority of lower eyelid blepharoplasties should be performed via a transconjunctival approach Excessive skin rarely needs to be removed in younger patients since it takes more skin to fill the concavity remaining after removal of orbital fat than it did to cover the antecedent convexity formed by the herniated fat (Fig 1.3B) Transcutaneous lower eyelid blepharoplasty should be reserved for elderly patients with excessive festoons (bags on bags) or patients with an entropion that needs repair by reattaching the capsulopalpebral fascia (see chap 3, “Entropion Repair”) with a bipolar cautery (Fig 1.12A–D) Before releasing the fat, grasp it with forceps and inspect it for bleeding If there is none, release the fat back into the orbit (Fig 1.13) It is much easier to cauterize visible vessels before they have retracted into the orbit If you release a bleeding fat pad into the orbit, expose it by applying gentle pressure to the globe, grasp the fat with forceps, and cauterize the bleeding vessel again Approach the medial fat pad in a similar fashion Apply pressure to the globe, prolapse the fat pad (Fig 1.14A), dissect it with the Ocutemp cautery (Fig 1.14B), cauterize the overlying vessels (Fig 1.14C), clamp and excise the fat pad (Fig 1.14C–E), cauterize the stump of fat, and maintain control and observe for bleeding before releasing the hemostat (Fig 1.14C and D) Use bipolar cauterization for hemostasis The middle fat pad may be removed in a similar fashion (Fig 1.15) The inferior oblique muscle lies between the medial and middle fat pad and is easily identified and avoided (Figs 1.2 and 1.16) It is very difficult to cause clinical diplopia by inadvertent injury to the inferior oblique muscle, as any experienced eye muscle surgeon can relate that the inferior oblique muscle continues to function quite well when partially removed After obtaining hemostasis, inspect the eyelid for contour and symmetry (Fig 1.17A and B) Reattach the conjunctiva and recess it about mm posterior to its original attachment to the tarsus (Fig 1.18A and B) Reattaching the conjunctiva avoids potential pyogenic granuloma formation Now tighten the lower eyelid, if necessary, with a tarsal strip procedure TARSAL STRIP PROCEDURES Technique Inject a local anesthetic containing epinephrine into the eyelid 10 to 15 minutes prior to surgery (Fig 1.4) Pass two 4-0 silk traction sutures through the eyelid margin and invert the lower eyelid Inject ½ to cm3 of anesthetic solution beneath the palpebral conjunctiva (Fig 1.5) A lateral canthotomy (Fig 1.6) may or may not be performed A canthotomy often facilitates removal of the lateral fat pad avoiding an unsightly inferior orbital mass after surgery Make an incision through the conjunctiva just posterior to the tarsus and extend it along the entire horizontal length of the eyelid (Fig 1.7A–C) Pass two 6-0 Vicryl™ traction sutures through the conjunctiva applying upward traction with hemostats (Fig 1.8) Dissect a conjunctival flap and obtain hemostasis with a hot Ocutemp™ cautery (Fig 1.9A and B) This exposes the lower eyelid fat pads Enhance exposure by retracting the lower eyelid with a Desmarres or similar retractor (Fig 1.3) Use bipolar cauterization to coagulate any large overlying blood vessels (Fig 1.10) Expose the inferior orbital fat pads by dissecting with the Ocutemp cautery Enhance exposure of the fat pads by applying gentle pressure on the globe (Fig 1.11A and B) Clamp the prolapsed fat with a hemostat, excise it with scissors, and cauterize the clamped fat Variations on the theme of tightening the lateral canthal tendon are the mainstays of lower eyelid surgery Do this by splitting the canthus for lesser degrees of laxity, splitting the eyelid into an anterior and posterior lamella for greater degrees of laxity, or tightening the common canthal tendon to treat rounding of the canthus and mild canthal dystopia These procedures are so important that they are worth describing in the context of lower eyelid blepharoplasty and later when discussing ectropion repair Clamp the lateral canthus and incise it with scissors (Fig 1.19) Extend the lateral canthotomy incision with a sharp blade (Fig 1.20) Dissect the lower eyelid into an anterior (skin and orbicularis muscle) and posterior lamella (tarsus and conjunctiva) (Fig 1.21) A horizontal cut posterior and parallel to the tarsus forms a tarsal strip (Fig 1.22) Pass a double-armed 5-0 Dexon™ or polypropylene suture with a large curved needle through the tarsal strip from posterior to anterior and tie it to prevent it from pulling through the tissue (Fig 1.23) Pass both arms of the suture through the lateral orbital wall at the level of the lateral orbital tubercle This suture placement has classically been described as through the periosteum at the lateral orbital rim, but you will get much better fixation of the eyelid to the lateral orbital rim if you pass the atlas of oculoplastic and orbital surgery (A) Figure 1.1 Preaponeurotic fat pads of the upper and lower eyelids Figure 1.2 The inferior oblique muscle lies between the medial and central fat pads (B) Figure 1.3 Apply gentle pressure to the globe This facilitates exposure of the lower eyelid fat pads (A) It takes more skin to fill a concavity than a convexity hence most patients can undergo a transconjunctival blepharoplasty without an external incision and removal of skin (B) lower eyelid surgery (A) Figure 1.4 Blanching of the skin at the operative site indicates sufficient vasoconstriction to enhance hemostasis and greatly facilitates the operation It is very helpful to inject the anesthetic in the preoperative holding area and let the epinephrine constrict the vessels while the patient is prepared for surgery Figure 1.5 Invert the lower eyelid with a 4-0 silk suture and inject additional anesthetic beneath the conjunctiva (B) Figure 1.6 A lateral canthotomy (A) with or without a cantholysis facilitates exposure of the lateral fat pads (A, B) Cantholysis entails cutting the inferior crus of the lateral canthal tendon (B) (A) (B) (C) Figure 1.7 Make an incision just below the tarsus (A) and extended it along the entire horizontal length of the eyelid (B, C) orbital surgery, optic nerve sheath decompression, and temporal artery biopsy (A) (B) Figure 9.35 Lower eyelid retraction and fistula (A) due to adherence to an orbital floor implant evident on CT scan (B) Figure 9.36 Severe lower eyelid retraction secondary to adherence to a bone graft the procedure Use a periosteal elevator to reflect the lacrimal sac and nasolacrimal duct behind intact periosteum (Fig 9.48) Enter the ethmoid sinus with a hemostat at the juncture of the ethmoid and lacrimal bone The bone is thin and easily penetrated This is a good time to decongest the ethmoid sinus Directly pour Afrin into the hole you made in the ethmoid bone This is facilitated by using an angiocatheter and a syringe Use a malleable retractor to gently retract the periorbita while you remove the medial orbital wall and ethmoid sinus mucosa with Kerrison rongeurs and a Takahashi rongeur (Fig 9.49) The medial orbital wall is thin and easily fractured and removed Locate the anterior ethmoidal vessels and keep the bone removal inferior to them This will avoid penetration of the cribriform plate with resultant cerebrospinal fluid leak (Fig 9.48) The apex of the orbit is recognized by a confluence of periosteal fibers forming a white band This is the end point Obtain hemostasis with afrinized cottonoids Locate the medial rectus with the 4-0 silk suture that you placed under its insertion at the beginning of the procedure Use a #12 blade (or any small, curved sickle blade), insert it into the incision and engage the posterior periorbita above and below the medial rectus muscle Draw the blade anteriorly, incising the periorbita and allowing the orbital fat to prolapse This avoids incising the medial rectus with resultant bleeding If orbital bleeding does occur, control it with bipolar cauterization Do not use Bovie cauterization in the orbit It may injure to the optic nerve Be careful to avoid the lacrimal sac and duct while extending the incision anteriorly If you suspect that you have injured either one, instill hyaluronic acid (Healon®) into the lacrimal system via the punctum If the lacrimal system is damaged, it can be repaired at that time Often, a simple suture repair is all that is necessary Pass a hemostat into the nose and enter the wound through the nasal mucosa Grasp the afrinized Vaseline gauze with the hemostat and pull some out of the nostril Use this to pack the nose The remaining gauze is used to pack the ethmoid sinus The packing may be removed the following morning or the evening of surgery by pulling it out of the nose Removing the packing is also an excellent way to rapidly decompress the orbit if a postoperative hemorrhage occurs The blood in the sinus will drain from the nose, relieving the optic nerve compression and allows you time to regroup, return to the operating room, and stop the bleeding if necessary 107 atlas of oculoplastic and orbital surgery (A) (A) (B) (B) (C) Figure 9.37 Patient referred with severe hypo-ophthalmos (A) secondary to a large orbital floor fracture evidenced on CT scan (B) Same patient after surgical repair of orbital floor (C) Have scan and skull available in the operating room and consult them before and during surgery as needed Look at the coronal CT scan and determine how thick the roof of the ethmoid sinus is If it is thick, it is less likely to be injured with a resultant cerebrospinal fluid leak The roof of the ethmoid is the cribriform plate (the base of the brain) and it is located just superior to the ethmoidal neurovascular bundles (Fig 9.50) Locate the anterior ethmoidal vessels and stay inferior to them Also, avoid torquing motions with 108 (C) Figure 9.38 Greenstick fracture of the orbital floor causing diplopia and restriction of both up and down gaze (A, B) CT scan demonstrates a posterior orbital floor fracture with inferior rectus muscle entrapment (C) These should be repaired expeditiously and are often challenging the Takahashi rongeurs when working near the cribriform plate Clean bites of bone with a Kerrison rongeur are much safer If a cerebrospinal fluid leak occurs, recognize it First, differentiate it from the Afrin you have placed in the sinus Suction it out If the clear fluid is Afrin, it will disappear completely If it is cerebrospinal fluid, it will continue to leak and flow What you now? Attempt to repair the fracture causing the leak This once required packing the boney defect with fat or muscle and applying a layer orbital surgery, optic nerve sheath decompression, and temporal artery biopsy (A) (B) (C) Figure 9.39 This patient had several previous surgeries attempting to free the entrapped inferior rectus The patient was referred with diplopia and restricted upgaze (A, B) CT scan demonstrates a posterior “greenstick” fracture entrapping the inferior rectus muscle (C) Repair required a combined approach from the orbit and maxillary sinus Note the relationship between the fracture, the back wall of the maxillary sinus, and the optic nerve Appreciate how you can approach a posterior orbital floor fracture with relative safety through the sinus, whereas intraorbital manipulation alone may well cause optic nerve damage of Surgicil and superglue or mobilizing a nasal mucosal flap to plug the leak This is more easily accomplished by instilling fibrin thrombin sealant (Evicel™) into the boney defect This should successfully resolve the cerebrospinal fluid leak Treat the patient with perioperative antibiotics for infection prophylaxis Always operate from the same position when performing this surgery This sounds both anal and banal but it is good advice Stand on the lateral side of the orbit you are operating on This allows you to retract the orbital contents with a malleable retractor and stay oriented You know exactly where the orbital contents are (behind your retractor) and you cannot inadvertently injure them This also allows direct visualization of the ethmoid sinus mucosa and the medial orbital wall that you are removing and the cribriform plate that you not wish to remove Every important structure is in view minimizing chances of accidental damage Do not rongeur what you cannot see If excessive bleeding impairs visibility, stop operating Afrinize and pack the sinus mucosa and wait a few minutes The bleeding will slow and stop It almost always does Be cautious in removing the posterior portion of the medial orbital wall This is an excellent time to stop and consult the axial CT scan and see just what is adjacent to the posterior orbital wall—posterior ethmoid sinus or sphenoid sinus Penetrating the posterior wall or the ethmoid sinus or the anterior wall of the sphenoid sinus enhances the boney orbital decompression Penetration of the posterior sphenoid enters the brain and is inviting disaster OPTIC NERVE SHEATH DECOMPRESSION Several techniques have been described for decompressing the optic nerve My tried and true method is via a transconjunctival medial orbitotomy and has been successful and essentially free of major operative complications in over one thousand cases It can be safely performed as an outpatient procedure under local anesthesia with sedation I instill peribulbar anesthetic with an angiocatheter in almost all extraocular muscle surgery and optic nerve sheath fenestrations This allows excellent anesthesia and analgesia with essentially no risk of damage to the globe or optic nerve 109 atlas of oculoplastic and orbital surgery (A) (B) (C) (D) Figure 9.40 Large orbital floor implants may exert excessive pressure on the optic nerve causing visual loss (A–C) Remove the implant (D) Figure 9.41 Hyperophthalmos secondary to a large implant on the orbital floor Treatment requires removing the implant and replacing it with a more appropriately sized implant One percent plain xylocaine with hyaluronidase is injected into the lateral canthal area to minimize eyelid motion and test the level of intravenous sedation No harm is done if the patient makes an abrupt move with a needle under the lateral canthus skin, but with the needle under the conjunctiva, a sudden motion may convert an extraocular case to an intraocular procedure Using a 30-gauge needle, approximately cm3 of anesthetic is 110 injected beneath the conjunctiva (Fig 9.51), ballooning it up quite nicely to facilitate the conjunctival peritomy Perform a 360-degree peritomy with scissors (Fig 9.52) Make a relaxing incision superior and inferior to the medial rectus Use blunt scissors to create a tunnel between the medial and inferior rectus Place an 18 or 20 gauge shortened angiocatheter in the tunnel and instill to cm3 of anesthetic into the peribulbar space (Fig 9.53) The eye bulges forward and the pupil promptly dilates as the anesthetic rapidly spreads through the anterior orbit Pass a 6-0 Vicryl suture through the medial rectus muscle posterior to its insertion and fixated it in three places Disinsert the muscle leaving a to mm stump of muscle at the insertion Two 6-0 Vicryl sutures are passed through the superior and inferior stump at the insertion These will be used to abduct the eye, retracting it laterally to expose the optic nerve sheath (Fig 9.54) By leaving a to mm muscle stump to suture, you minimize the possibility of penetrating the globe when passing sutures through the insertion site Retract the medial rectus muscle behind a Sewall ethmoidectomy retractor Any flat blade retractor of appropriate size will do, but there is a handle on the Sewall retractor, which greatly facilitates retraction, avoiding a tight grip and subsequent tremulous orbital surgery, optic nerve sheath decompression, and temporal artery biopsy (A) (A) (B) (B) Figure 9.42 Severe orbital emphysema (A) after medial orbital wall fracture evident on CT scan (B) Note the relationship of the medial rectus muscle to the fracture site in the medial orbital wall This muscle is not entrapped and extraocular mobility was normal after the swelling subsided fingers With the eye retracted in abduction and the medial rectus retracted medially, the muscle cone is exposed (Fig 9.54) Proceed posteriorly towards the optic nerve This is facilitated by bluntly displacing the orbital fat with small neurosurgical cottonoids and cotton-tipped applicators (Fig 9.55) Sharp dissection and nerve hooks are not necessary at this stage of the operation Several attempts at retracting the orbital fat are usually necessary and exposure of the optic nerve sheath becomes easier as the manipulation softens the globe It is often helpful to place the Sewall retractor over a few cottonoids This also protects the medial rectus from excessive bruising The optic nerve sheath, covered by short ciliary vessels and nerves, is identified at its juncture with the globe These are manipulated with a dull nerve hook exposing an area of nerve sheath devoid of overlying structures (Fig 9.56) This is the ideal area to incise with a small, sharp pointed blade (Fig 9.56) Incise the sheath and if the surgery was indicated, you will be rewarded with an egress of cerebrospinal fluid (C) Figure 9.43 Patient has a medial orbital wall fracture with medial rectus entrapment Eyes are straight in primary gaze (A) Right gaze is unimpaired (B) Abduction is significantly impaired in left gaze (C) and forced ductions are positive The patient needs surgery Enlarge your incision by bluntly spreading it with two nerve hooks before releasing traction and letting the globe rest (Fig 9.57) This maneuver facilitates finding your incision when you re-expose the operative site 111 atlas of oculoplastic and orbital surgery Figure 9.44 Rounding of the medial canthus and widening of the intracanthal distance are the hallmarks of medial canthal tendon disruption in traumatic telecanthus Figure 9.45 CT scan demonstrates enlarged medial recti muscles causing a compressive optic neuropathy in a patient with dysthyroid orbitopathy Figure 9.46 Axial fresh cadaver section demonstrating the relationship between the medial orbital wall and the intracranial structures at the orbital apex 112 Figure 9.47 Gull wing incision outlined in the medial canthus This incision gives excellent access to the medial orbital wall and very acceptable cosmesis Figure 9.48 Relationship between the anterior ethmoidal artery, the medial canthal tendon, and the lacrimal sac Figure 9.49 Removal of the medial orbital wall inferior to the anterior ethmoidal artery orbital surgery, optic nerve sheath decompression, and temporal artery biopsy Figure 9.50 Diagram demonstrating the relationship between the anterior ethmoidal vessels, medial canthal tendon, and lacrimal sac The ethmoidal vessels are the key landmark to avoid damage to the cribriform plate Figure 9.51 Subconjunctival injection of anesthetic solution Figure 9.52 A 360-degree peritomy is made with curved scissors Figure 9.53 A blunt cannula or shortened angiocatheter is inserted in the peribulbar space between the medial and inferior rectus muscles Figure 9.54 A 6-0 Vicryl suture passed through the medial rectus insertion abducts the eye The medial rectus muscle is retracted exposing intraconal fat and the posterior ciliary vessels Failure to so may result in a “lost incision” and necessitates making another incision into a now decompressed optic nerve sheath This invites violation of the optic nerve although this is rarely clinically significant Why? Because you are dealing with peripheral nasal fibers subtending far peripheral temporal visual field, which will rarely be missed This is also a good reason to avoid the lateral approach to the optic nerve where you are incising over the papillomacular bundle An overzealous incision into the optic nerve fibers here will injure the papillomacular bundle and will surely be noticed after surgery Re-expose the now incised optic nerve sheath, find your enlarged incision, and put the tip of a blunt, bent nerve hook into it Retract the incision with the nerve hook and incise and excise 113 atlas of oculoplastic and orbital surgery Figure 9.55 Cottonoids and cotton-tipped applicators are used to reposition the orbital fat and expose the optic nerve sheath and its overlying vessels The medial rectus muscle is retracted with a blade retractor Figure 9.56 The short ciliary vessels are manipulated and retracted with a blunt nerve hook and the optic nerve sheath is incised with a sharp, pointed blade as much of the sheath with microscissors (I prefer vitreoretinal scissors) as you are comfortable doing (Figs 9.57 and 9.58) Trabeculations in the subarachnoid space between the optic nerve and its sheath may be lysed with blunt nerve hooks (Fig 9.59) This maneuver is actually overrated and in my experience rarely necessary Your comfort level will vary with the quality of exposure, preoperative visual function, location of overlying short ciliary vessels, and your surgical experience This is the end of the procedure Inspect the operative site for bleeding When present, this can almost always be controlled by gentle pressure applied with a moist cottonoid Bipolar cauterization is rarely needed and if used should be very low power in a wet field Most all bleeding will stop and with a little patience and pressure this will also Remove the sutures from the stump of the medial rectus insertion and reattach the medial rectus to its insertion with the previously 114 Figure 9.57 The incision is spread apart and elevated from the optic nerve with two nerve hooks while it is incised with microscissors Figure 9.58 A portion of the optic nerve sheath is excised Note sparing of the short ciliary vessels placed double-armed suture Recess it to mm depending on how much muscle you excised at the insertion A hang-back recession is fine (Fig 9.60) Close the conjunctival peritomy with a few 6-0 Vicryl sutures with buried knots and patch the eye with your antibiotic/steroid ointment of choice Complications Significant complications are relatively uncommon after wellperformed optic nerve sheath decompression In reality, this is little more than an extended medial rectus recession If the operation is indicated, the nerve sheath is distended with cerebrospinal fluid, it is readily visualized and can be incised with minimal manipulation and trauma Problems arise when exposure is limited and manipulation is excessive and prolonged Release pressure on the globe every one to two minutes to avoid ischemic injury to the optic nerve or orbital surgery, optic nerve sheath decompression, and temporal artery biopsy to check the patient’s vision prior to discharge from the recovery area Do not keep the eye retracted and clamped in abduction for more than a minute at a time without releasing it and restoring circulation to the optic nerve I think that this is a key step in avoiding intraoperative complications A minute or so is more than ample time to perform the various sequential steps described here Exposing the optic nerve sheath is easiest in those patients really needing the operation The nerve sheath is distended and contains a significant amount of fluid under pressure When operating on patients who have been treated medically for a time, discontinue their medications for a few days before surgery to allow their cerebrospinal fluid pressure to increase and distend the optic nerve sheath, making the operation much easier A corollary to this is that when performing bilateral optic nerve sheath decompression in a patient with one good eye and one bad eye operate on the good eye first and enjoy the advantage of a distended optic nerve sheath It really does make the surgery much easier and safer both by facilitating exposure and by protecting the optic nerve from the surgeon’s blade with a layer of cerebrospinal fluid TEMPORAL ARTERY BIOPSY Figure 9.59 The fenestration is completed by lysing the trabeculations in the subarachnoid space with blunt nerve hooks allowing more cerebrospinal fluid to egress An assistant using a cotton-tipped applicator can enhance exposure during the operation by applying gentle pressure to the globe or retracting orbital fat Figure 9.60 The medial rectus is reattached to the globe at its insertion or it may be recessed a few millimeters The conjunctiva is closed with several sutures Bury the knots Close the conjunctiva carefully to avoid corneal dellen formation retina Do not aggressively cauterize bleeding vessels The bleeding will stop with gentle pressure and time Caveats Use plain lidocaine with hyaluronidase to avoid epinephrine induced vasoconstriction It is also short acting enough to allow you Over the past 30 years, I have watched a variety of surgeons including, on occasion, myself make fools of themselves performing this simple procedure Blunders observed have included failure to find the artery after two hours exploration, biopsy of the vein, and excessive bleeding due to uncontrolled, accidental early incision into the artery The technique presented here is simple and relatively foolproof Technique If you can palpate the superficial temporal artery, you can biopsy it in the office or in the surgical center Patients with true temporal arteritis often have very obvious, chord-like superficial temporal arteries bulging in their temporal fossa (Fig 9.61) These patients will often have positive biopsies (Fig 9.62) When less obvious, the artery can be palpated and outlined with a marking pen In patients with a barely palpable superficial temporal artery, a Doppler unit can be used to identify the artery in the preauricular region and trace it to the temporal region This is not often necessary but very helpful in some cases If a Doppler is not available, the artery may very often be located cm in front and superior to the ear (Fig 9.63) After the incision site over the artery has been identified (Fig 9.64), inject the operative site with plain lidocaine Do not use lidocaine with added epinephrine for it will constrict the artery and make the procedure much more difficult Make an incision through the skin and superficial dermis Grasp both sides of the incision and elevate it from the underlying tissue Incise it with scissors, insert a hemostat, and spread it apart (Fig 9.65A and B) Open the incision with scissors This technique should allow you to expose the artery without injuring it and causing excessive, premature bleeding (Fig 9.66A and B) The artery lies on the superficial temporal fascia (Fig 9.67) Grasp the artery with blunt forceps and dissect it from the surrounding tissue with scissors Pass a hemostat beneath the artery and replace it with a 4-0 silk suture Use the suture to retract the 115 atlas of oculoplastic and orbital surgery Figure 9.64 Mark the course of the artery or an incision adjacent to it Note that the patient’s artery is located exactly where described in Figure 9.63 Figure 9.61 Patient with a large, chord-like superficial temporal artery (A) Figure 9.62 Floridly positive temporal artery biopsy with a plethora of giant cell granulomas (B) Figure 9.63 The superficial temporal artery can often be located cm above and in front of the earlobe 116 Figure 9.65 Elevate both sides of the incision from the underlying tissue and spread the incision with a hemostat (A, B) orbital surgery, optic nerve sheath decompression, and temporal artery biopsy (A) (A) (B) (B) Figure 9.66 The superficial temporal artery enveloped in surrounding tissue (A) which is dissected from it with scissors (B) Figure 9.68 The distal and proximal ends of the artery are clamped with hemostats (A) and the specimen excised (B) Figure 9.67 The surrounding tissue has been removed and the artery exposed on the superficial temporal fascia Figure 9.69 The proximal and distal ends of the artery are cauterized and sutured if necessary vessel and facilitate further dissection After an ample specimen has been isolated (Fig 9.68A), clamp both ends of the vessel with hemostats and excise the specimen (Fig 9.68B) Cauterize the stumps of the vessel If the artery is large and functional, apply a silk suture tie to the proximal end in addition to cauterizing it (Fig 9.69) After hemostasis is completed, close the subcutaneous tissue with 5-0 Dexon sutures and apply Indermil to the skin edges or suture them with your skin suture of choice 117 Index American Journal of Ophthalmology 26 Aqueous tear deficiency 84 Asymmetric eyelid creases 82, 83 Atypical mycobacterium infection 82 “Belt and belly” phenomenon 40 Bilateral ectropion 38, 40 Bilateral keratopathy 77 Bilateral lower eyelid retraction 36 Bipolar cauterization 1, Blepharoplasty 59–60 chronic irritation after 76 eyelid retraction and 72 Blinking (incomplete), after upper eyelid surgery 73 upper eyelid retraction 73 Boney orbital floor surgeon’s view of 106 Brow lift through eyelid crease incision 66, 68 Brow ptosis repair 64, 66 Canaliculi relationship between eye/lacrimal sac and 86 Canthotomy Capsulopalpebral fascia inferior orbital fat pads above 29 levator aponeurosis and 31 sutures through 30 tightening and tying 30 Cauterization inspection for bleeding and medial fat pad “Cheese wire,” 26 Chemosis 38, 39 Chemotic conjunctiva 38, 39 after lower eyelid surgery 39 Chronic irritation after ptosis surgery/blepharoplasty 76 Cicatrical ectropion 16, 17, 25 after face lift and lower eyelid blepharoplasty 21 cicatrizing forces 21 less severe 41 skin graft 21 closing donor site 24 determining size of 23 larger 22 pinch skin graft from upper eyelid 22 thinning 24 Congenital ptosis 63 Conjunctiva anesthetizing 26, 27 incision through 1, in palpebral fissure 85 repositioning Conjunctival flap, dissecting Conjunctivochalasia 84, 85, 88, 89 dry eye vs 88 technique 92–94 118 Corneal erosions exposed implant causing 36 and foreign body sensation 45 Coronal brow lift hemorrhage after 66 Cryoprobe 103 Dacryocystorhinostomy (DCR) 84 Dehisced capsulopalpebral fascia 26 Diplopia 38, 80, 82 Distichitic eyelashes 89 Dry eye 84 ocular lubrication and temporary punctal occlusion 84 severe 85 vs conjunctivochalasia 88 Ectropic puncta 85 Ectropion with lower eyelid laxity 16, 17 cutting posterior lamella 20 split into anterior and posterior lamellae 20 repair 16–25 tying suture inverts punctum and corrects 19 skin removal causing 38, 41 Edema after upper eyelid surgery due to atopic reaction 75 during ptosis surgery 73 and chemosis 38 Encapsulated tumors 98 ENDURAGen graft 32, 33, 34 applying sealant 35 fixing in appropriate position 35 outlining and excising 34 placing cottonoid 35 ENDURAGen implant 33 Entropion repair 26–31 cicatrical ectropion after 30 complications 26 obviating 26, 28 right lower eyelid 29 suture 26, 28 complications 26 Evicel™ 25, 32 Extruding Enduragen implant 44 Eyelid retraction 70–72 and blepharoplasty 72 buckling of ENDURAGen graft, recurrent 36 skin removal causing 38, 41 Eyelid thickening 36 Fat pads exposure of medial and lateral 13 hemostasis, technique for 43 removal of 55 Fibrin/thrombin sealant 34 Floppy upper eyelids 89 index Frank ectropion 26, 28 Frost suture 24, 35 The Garfield look 70 resolution of 71 Gull wing incision 112 Hemorrhage 38, 42, 45 after uneventful ptosis surgery 74 after upper eyelid surgery 73 and orbital fat pads 43 postoperative 42 slowly resolved 74 upper eyelid, shortly after ptosis surgery 75 Herring’s law 52 of equal innervation 52 Human skull 97 Hyperophthalmos 110 Hypertrophic scarring 60 Hypo-ophthalmos 108 Involutional entropion 26, 27 Kennerdell–Maroon retractor 97, 100 Keratopathy caused by decreased spontaneous blink 77 inferior punctate 52 suture 55, 79 avoiding potential 53 Kerrison rongeurs 84 Lacrimal fossa, suture repositions gland in 58 Lacrimal gland biopsy 55–56, 58 multiple passes through 58 prolapse 57 retracted 58 tumor 56 Lagophthalmos 64 after upper eyelid surgery 73 in down gaze 76 Lateral canthal skin excised beneath in 14 tendon plication, technique of 46–47 Lateral canthotomy 1, incision, extending 8, 19 Lateral canthus clamping extending incision rounding of 47 subciliary incision and extending over 13 Lateral canthus, rounding of 45 Lateral orbital rim extending lateral canthotomy incision to expose 19 passing suture needles through bone of 19 periosteum of superior 58 Lateral orbital tubercle 11 Lateral orbital wall 12 replaced 103 Lateral orbitotomy with bone removal 96–98 Levator aponeurosis 31 advancing and tightening 71 dehisced 59, 60 double-armed suture are passed through 55 surgical anatomy of 71 Levator muscle extirpated 64 fatty infiltrated 49 Lissamine green staining devitalized tissue 51 for dry eye diagnosis 85 Lower eyelid approaching via transconjunctival incision fat pads in 1, inferior oblique muscle 1, retraction 32–37 complications 32, 37 technique 32 surgery 1–15 complications of 38–47 Lower eyelid blepharoplasty 38, 40 rounding of lateral canthus 45 transconjunctival tarsal strip procedures technique Lower eyelid retraction 38, 73, 77 causing inferior superficial punctate keratopathy 38, 41 fistula 107 problem 77–78 recognizing and repairing 51 severe 107 Lower eyelid surgery hemorrhage after 44 Medial canthal webbing 79, 80 Medial fat pad distinguished from yellow preaponeurotic fat pad 51 exposing and cauterization 6–7 inferior oblique muscle separating middle from removal of 57 Medial orbital decompression 102, 106–109 Medial orbital fat pad 50 prolapsing 51 Medial orbital wall fractures 102 Medrol® 38 Mini-incision direct brow lift 68–69 dividing sub-brow tissue 69 outlining incision 68 passing through posterior brow flap 70 problems and solutions 69–70 retracting superior portion of incision 69 tying suture 70 undermining incision 68 Nasal and temporal sutures Nasal mucosa, exposed 87 Oblique muscle, inferior applicator stick points to 14 and medial fat pad Ocular surface dysfunction, detection and treatment of 84 Ocutemp cauterization 55 Ocutemp® cautery 1, Ocutemp hot cauterization Optic nerve sheath decompression 109–114 complications 114–115 Orbital decompression 98 Orbital emphysema 111 Orbital fat pads failure to remove 38 inferior 26 skin muscle flap exposing 13 removal of 5, 13 119 index Orbital floor fracture repair 99 Orbital lesions lateral 100 medial apical 99 Orbital septum 49, 56 levator aponeurosis/muscle separated from 53, 54 Orbital surgery 95 optic nerve sheath decompression/temporal artery biopsy 95–117 surgical approaches to 97 Orbital tumor apical 98 diffuse 96 encapsulated 96 distinct from adjacent optic nerve 99 human skull and 97 isolated 102 large posterior encapsulated requiring craniotomy and superior orbitotomy 97 superior lateral 100 Orbital wall fracture with medial rectus entrapment 111 periosteum of lateral 100 Orbitotomy completed 102 inferior 98–99 Osteotomy superior/inferior 101 Oval wedge of conjunctiva and subconjunctival tissue 16, 17, 18 Palpebral conjunctiva 1, Periosteum and lacrimal sac 87 Pinch blepharoplasty 60–62 successful 62 Postoperative suture keratopathy, preventing 80 Preaponeurotic fat pads upper/lower eyelids Preaponeurotic fat pads levator aponeurosis/muscle separated from 49, 53, 54 medial fat pad appears whiter 55, 57 and prolapsed lacrimal gland/ superior orbital rim 50 Preseptal orbicularis muscle 53, 54 Prolapsed lacrimal gland 49 vs lateral preaponeurotic fat pad 58 Prolapse repair 55–56, 58 Ptosis surgery 52 chronic irritation after 76 iopodine on mild to moderate, beneficial effect of 79 of left upper eyelid 52 long-standing asymmetric result after 78 prolapsed lacrimal gland during 55 recurrent 81 technique 52–53 upper eyelid edema after 79 upper eyelid hemorrhage shortly after 75 Ptosis with absent levator function 62–64 contour adjustment 65 fixating loops 64 folding end of sling to tarsus 65 problems and solutions 64 Punctal ectropion 16, 17 lissamine green staining of 17 Punctum, dilating and irrigating 86 Pyogenic granuloma 38, 42 120 Recurrent entropion 31 Recurrent lower eyelid retraction 37 Restasis® 84 Sialastic tubing 87 Snap-back test 88 Subtle punctal ectropion 85 Supraclavicular graft 25 Supramid slings 62, 63 Surgical entropion repair, technique 26 Suture placement superficial 10 Tarsal strip procedure 1, 8, 16 double-armed suture and 20 lateral orbital rim 20 passing sharp, curved needle shortening eyelid with 41 stitching 9–10 tightening eyelid 31 Tarsus 54 Tearing and dry eye–evaluation and treatment 84–94 Telfa bolster 25 Telfa template 23 Temporal artery biopsy 115 technique 115, 117 Temporal brow ptosi 67 Transconjunctival blepharoplasty 1, Transconjunctival dissections Transconjunctival lower eyelid surgery 38, 39 Transcutaneous figure of eight suture, diagrammatic representation of 17 Transcutaneous lower eyelid blepharoplasty 1, 10–15 preventing excising excessive amount of skin 14 Transcutaneous lower eyelid surgery 38, 39 Tumor biopsy and removal 97 Upper eyelid crease 61 edema, after ptosis surgery 79 excessive removal of skin resulting incomplete closure/ lagophthalmos/ keratopathy 60 mild peaking and retraction of 78 multiple layers of 48, 49 preaponeurotic fat pads in 57 ptosis of 52 redundant skin 61 Upper eyelid laxity 89 Upper eyelid surgery 48–72 anatomy 48 complications of 73–83 cosmetic, vertical diplopia immediately after 81 intraoperative complications 58–59 patient selection 48, 52 persistent erythema and nodules after 82 red painful eye after 80 Vasoconstriction 53 hemostatic effect of 53 Vasoconstriction, optimal epinephrine induced 26 6-0 Vicryl™ sutures 1, 32 Visual loss 38, 43, 45 Wedge resection upper eyelid 90, 92, 94 Windshield wiper epitheliopathy (WWE) 88 Atlas of Oculoplastic and Orbital Surgery About the book This book is a practical, problem-orientated guide to the management of common oculoplastic and orbital disorders, and provides simplified solutions to complex problems This text covers upper and lower eyelid surgery and repair as well as orbital surgery, and the prevention and treatment of potential complications With superb colour surgical photographs and illustrations, Atlas of Oculoplastic and Orbital Surgery is essential reading for ophthalmologists, oculoplastic surgeons, neuro-ophthalmologists and plastic surgeons About the author Thomas C Spoor MD FACS, joined the Sarasota Retina Institute, Florida, USA in 2006, while also maintaining a private practice in Detroit, Michigan, USA Dr Spoor is renowned the world over for his pioneering work in oculoplastic, orbital and neuro-ophthalmic surgery In his extensive academic and medical career, spanning 30 years, special recognition has been celebrated for his dedication in the field of optic nerve surgery, as well as his ground-breaking treatments of patients with optic nerve and orbital dysfunction Also available Atlas of Neuro-Opthalmology By Thomas C Spoor (ISBN: 9781853177736) Controversies in Neuro-Ophthalmology Edited by Andrew G Lee, Jacinthe Rouleau and Reid Longmuir (ISBN: 9781420070927) Garner and Klintworth’s Pathobiology of Ocular Disease, Third Edition Edited by Gordon K Klintworth and Alec Garner (ISBN: 9780849398162) Practical Manual of Ocular Inflammation Edited by Andrew D Dick, Annabelle A Okada and John V Forrester (ISBN: 9780849391835) Facial Rejuvenation By Thomas C Spoor and Ronald L Moy (ISBN: 9781853177743) Telephone House, 69-77 Paul Street, London EC2A 4LQ, UK 52 Vanderbilt Avenue, New York, NY 10017, USA www.informahealthcare.com ... FACS Professor Emeritus Departments of Ophthalmology and Neurosurgery Wayne State University School of Medicine and Oculoplastic and Orbital Surgery St John Hospital System, Detroit, Michigan and. .. lateral orbital rim, but you will get much better fixation of the eyelid to the lateral orbital rim if you pass the atlas of oculoplastic and orbital surgery (A) Figure 1.1 Preaponeurotic fat pads of. .. (not periosteum as described for years) of the lateral orbital rim at the level of the lateral orbital tubercle (A, B) atlas of oculoplastic and orbital surgery Figure 1.25 Passing the needles